Remember when we used to share "good cases!" on here? Well, here's one.

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Before or after electrolytes came back?

Long before.

While I doubt it harmed anything I don’t know that I would congratulate myself for giving this patient tpa. It isn’t fixing her severe hyponatremia and electrolyte disarray, and while basilar stroke is a possible dx it’s also pretty rare and if it’s not present on the cta I wouldn’t pursue it further.

How did she do?

tPA given at the STRONG recommendation of neurology. She did fine. I felt the same way you do.

You definitely took the approach with the fewest emails and qa meetings.

I have been thoroughly spoiled by (admittedly not completely reliable) istat electrolytes. Can get them back in two minutes. Might have given you a stick to shake at them, but it takes a big stick to make those bastards retreat. Neuro likes to quote a body of literature on tpa being relatively safe in the non stroke patient. Helps me sleep at night. Not going to question it too much because of that.

Interesting case, would be one I would file to read up on later and see if they figured something out.
 
You definitely took the approach with the fewest emails and qa meetings.

You're right. Shame, isn't it?

I have been thoroughly spoiled by (admittedly not completely reliable) istat electrolytes. Can get them back in two minutes. Might have given you a stick to shake at them, but it takes a big stick to make those bastards retreat. Neuro likes to quote a body of literature on tpa being relatively safe in the non stroke patient. Helps me sleep at night. Not going to question it too much because of that.

I even was slow-throwing to neurology to allow time for some of the workup to come back. I couldn't "slack" any longer. It took ages to get the lytes back in this patient; likely because they were so far out of reference range.

Interesting case, would be one I would file to read up on later and see if they figured something out.

Homegirl is still in the ICU. More to develop.
 
Glucose Level 114 mg/dL HI
Sodium 120 mmol/L LOW
Potassium 1.7 mmol/L CRIT
Chloride 77 mmol/L LOW
CO2 23 mmol/L
Anion Gap 20 mmol/L NA
BUN 89 mg/dL HI
Creatinine 3.56 mg/dL HI
BUN/Creat Ratio 25 NA
Calcium 6.7 mg/dL CRIT
Albumin. Level 1.8 gm/dL LOW
TP 5.8 gm/dL LOW
A/G Ratio 0 NA
T Bili 0.6 mg/dL
Alk Phos 154 units/L HI
AST 263 units/L HI
ALT 100 units/L HI
eGFR Non-African American 13 mL/min/1.73m2 NA
eGFR African American 16 mL/min/1.73m2 NA
eGFR Pediatric Not Reported
Ethanol <3 mg/dL
Troponin I 0.244 ng/mL CRIT
Acetaminophen Lvl <2.0 mcg/mL LOW
Salicylate <1.7 mg/dL LOW

So what’s the best way to get work on these?

BUN/Cr suggests she’s quite dry. Mental status probably from the sodium, so do you go isotonic or hypertonic? Central line for aggressive potassium replacement? Or go big with a vas cath and dialysis, which might fix it all the fastest? Then again gotta worry about CPM, so you don’t want normal sodium too quickly.
 
That's an odd type of renal failure that presents without acidosis or hyperkalemia. Any prior labs? We've all seen the chronic Na of 120. BUN a little low for uremic encephalopathy.

If it's all acute: check Mag, CT head, 3% bolus and gtt, IV synthroid, replace lytes.

By the book, I don't see the indication for emergent HD. I would talk it over with nephro before placing a cath.
 
That's an odd type of renal failure that presents without acidosis or hyperkalemia. Any prior labs? We've all seen the chronic Na of 120. BUN a little low for uremic encephalopathy.

If it's all acute: check Mag, CT head, 3% bolus and gtt, IV synthroid, replace lytes.

By the book, I don't see the indication for emergent HD. I would talk it over with nephro before placing a cath.

I think electrolyte disarray significant enough to cause a coma is more important than a textbook value, but I might accept if someone wanted to trial fluids and see if she started making urine. Doing a couple runs of dialysis doesn’t mean she’s bound to do it for life.

From fox’s exam she doesn’t sound that dry and I agree the electrolyte picture is unusual for simple hypovolemia, which usually shows up with potassium on the other end of the spectrum even when people shi* their Brains out and are total body down. I think i would do steroids before I would do synthroid in this lady, but again the electrolytes are wrong and isn’t crashing, so would think carefully about that too.

Main thing that would cause me consternation is how rapidly to correct sodium and what fluid (I have met many people walking around with that sodium symptomatic, suggests this is acute), but I would probably punt on that unless I know I have to keep her a few hours. If she can go to the micu with renal following that’s where she belongs.

Having said that, up to date now supports an approach of 3% trial of 50 cc with recheck after 30 min to 1 hr, although I don’t know the literature behind that rec.

And though @thegenius might confiscate my board cert for it, I would order serum osmoles and urine osmoles, electrolytes and creatinine to help out our micu friends. The results can get messed with by fluid resuscitation, and she’s covered in literal shi*, so I would cath her for that urine. I would not attempt to follow the results or interpret them though if I’m being honest, getting a little out of my depth

Edit: also that potassium is as important to address as the sodium. She’s having frequent pvcs and if her hyponatremia didn’t cause a seizure for the initial syncope then she likely had a significant dysrhythmia from her k (which I would favor given frequent pvcs/possible trigemjny)
 
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Before or after electrolytes came back?

Long before.

While I doubt it harmed anything I don’t know that I would congratulate myself for giving this patient tpa. It isn’t fixing her severe hyponatremia and electrolyte disarray, and while basilar stroke is a possible dx it’s also pretty rare and if it’s not present on the cta I wouldn’t pursue it further.

How did she do?

tPA given at the STRONG recommendation of neurology. She did fine. I felt the same way you do.
Did they explain which occluded vessel produces this "stroke syndrome"?
 
They thought it was a basilar with a clean angio?
Lol, this is seriously, "WTF?!" to me. This is why I don't call stroke alerts on patients like this where technically their NIHSS is >20, but it is clearly not an ischemic stroke. Just get the CT/CTA immediately without calling an alert and only call neurology if there is actually a clot. I also would refuse to push tPA on a patient without focal deficits and a clean angio, especially if the neurologist has not even seen the patient. You are on the hook for any complications from tPA from that situation, not the neurologist.
 
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Thyroid panel might actually legit be useful here, if this is anything like the one extremely rare case I saw.

It's fairly obvious people on here haven't seen a real thyroid emergency. Bradycardic hypotension refractory to meds, pressors, and IVF resus is no joke.
 
Out of all the fuucked up electrolytes she has, the extremely low potassium is the single most deadly one. This has to be addressed first by the EP. You can get instant death from the resultant cardiac arrhythmia.

In fact I bet she had a cardiac arrhythmia that produced syncope which lead her to come to the hospital. I don’t think she had a seizure although its on the differential.

@dadaddadaBATMAN no criticism here for sending urine lytes and i would send other non-emergency stuff too. But can’t sit around and wait for them to return and skimming through UTD looking up the urine sodium values differentiating SIADH versus other stuff. It’s that K+ that has to be fixed!

The only other time i had a K+ of 1.8 the ICU doc wanted a central line and was nice enough to come down and place a subclavian one himself. These patients tend to have a massive whole body potassium deficit, more than one would expect by subtracting 4.0 - 1.8 = 2.2 mmEq down.

I don’t have a problem with the neuro workup first and i agree with the commentary that giving tPa with a clean angio with no focal neuro deficits is just Neuro covering their ass.

I would have called Nephro and ask their opinion on optimal resus in this case. They sometimes are good at identifying novel crystalloid replacement solutions with additives that we don’t think of.

I think she needs a line. Tube. Foley.
Good case. When I graduated from residency I was good at identifying this electrolyte imbalance shiit but working in a community hospital really sucks the intellectual curiosity out of you.
 
I think the fact that my average i-Gel'ed patient is a tiny, frail, brittle senior probably has something to do with it.

God, I hate Florida sometimes. A lot of times.

Are they using the correct size? i-Gels come in more than one size. Sounds like they're cramming a size 5 (90+ kg adult) when a size 3 (30-60 kg) should be used if the patient is tiny and frail.
 
Are they using the correct size? i-Gels come in more than one size. Sounds like they're cramming a size 5 (90+ kg adult) when a size 3 (30-60 kg) should be used if the patient is tiny and frail.

No disrespect/condescension meant.

...

I'm pretty sure the EMS crews only know so many numbers here. Oh, and 99% of the patients needing an iGEL are 90+kg because Americans are so fat that "sizing" is obviated by 'Merica.

Seriously, America. It's time that we win the #1 in the world prize when it comes to physical fitness. Not "#1 in the world when it comes to eating cookies for three meals and having a YouTube channel about your struggles."
 
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It's fairly obvious people on here haven't seen a real thyroid emergency. Bradycardic hypotension refractory to meds, pressors, and IVF resus is no joke.

Dude.

I get you. I totally dig your posts.

You are the 'disruptor' that I stopped being. Don't stop.

But... the patient is neither hypotensive nor bradycardic, and this ain't a thyroid case.

The fact that you ferret'ed (yep, I meant that as a complimentary verb) this idea out is freaking cooool.

Here's the unfortunate truth of *our* situation.

You said yourself a few posts back: "I'm considering a Crit-Care fellowship to escape the nonsense and the crunch."
I said to myself a few weeks back: "I'm considering a Crit-Care fellowship to escape the nonsense and the crunch."

(Now addressing the general population of SDN)

Here's my problem:

I hate the patients.

For every 1 patient who has a problem that can be fixed and needs to be fixed, there are (without exaggeration) 10-12 patients who are there because "its the EMERGENGY department, so its FREE becuzz GOVERNMENTS (sic)".

10 hour shift. 2.5 patients an hour. 25-30 patients a shift.

2 patients have a problem that can be fixed and needs to be fixed. Daily.

22 patients will just agitate you because they can't *life*.
 
16 days out from graduation...the last thing I need is more examples of things I don't know the answer too. Thnx RF!
 
Dude.

I get you. I totally dig your posts.

You are the 'disruptor' that I stopped being. Don't stop.

But... the patient is neither hypotensive nor bradycardic, and this ain't a thyroid case.

The fact that you ferret'ed (yep, I meant that as a complimentary verb) this idea out is freaking cooool.

Here's the unfortunate truth of *our* situation.

You said yourself a few posts back: "I'm considering a Crit-Care fellowship to escape the nonsense and the crunch."
I said to myself a few weeks back: "I'm considering a Crit-Care fellowship to escape the nonsense and the crunch."

(Now addressing the general population of SDN)

Here's my problem:

I hate the patients.

For every 1 patient who has a problem that can be fixed and needs to be fixed, there are (without exaggeration) 10-12 patients who are there because "its the EMERGENGY department, so its FREE becuzz GOVERNMENTS (sic)".

10 hour shift. 2.5 patients an hour. 25-30 patients a shift.

2 patients have a problem that can be fixed and needs to be fixed. Daily.

22 patients will just agitate you because they can't *life*.
It was more of a general reply for utility of thyroid studies, not for your case. Great case though. I agree 100%.
 
Speaking of weird cases, had a guy yesterday who had been fishing all day. Ate a salad and then had a "funny sensation in his throat" and "pounding sensation in his head" followed by numerous episodes of vomiting and diarrhea. Arrived in ED with BP in the 70's and HR of 40-50. EKG shows sinus brady. Labs all normal except for lactate of 2.5. Denies any chest pain, back pain, abdominal pain, dyspnea, or headache. EKG without ST-T changes, trop negative, CXR negative. Exam had no abdominal tenderness.

Thoracic Aortic Dissection... TTE upstairs showed a dilated root with regurgitation. STAT CTA then ordered. Went to the OR. Again, no chest, back, or abdominal pain. I didn't diagnose it. Curious how many would've ordered a CT on someone in their 70's with no abdominal tenderness/pain or chest pain.
 
I'm not EM but as a doc in a field that does not do diagnosis routinely, reading these undifferentiated cases and the diagnostic chops is better than most books. This could be the beginning of an episode of ER, Scrubs, or (gasp) the resident. And to see the RF flair of the description is like reading Tolkien levels of detail, but actually understanding it.

Just wanted to post my appreciation for OP and this thread, otherwise carry on.
 
Speaking of weird cases, had a guy yesterday who had been fishing all day. Ate a salad and then had a "funny sensation in his throat" and "pounding sensation in his head" followed by numerous episodes of vomiting and diarrhea. Arrived in ED with BP in the 70's and HR of 40-50. EKG shows sinus brady. Labs all normal except for lactate of 2.5. Denies any chest pain, back pain, abdominal pain, dyspnea, or headache. EKG without ST-T changes, trop negative, CXR negative. Exam had no abdominal tenderness.

Thoracic Aortic Dissection... TTE upstairs showed a dilated root with regurgitation. STAT CTA then ordered. Went to the OR. Again, no chest, back, or abdominal pain. I didn't diagnose it. Curious how many would've ordered a CT on someone in their 70's with no abdominal tenderness/pain or chest pain.

Probably not.

I had a thoracic (abd abdominal) aortic dissection and he was complaining of testicular and scrotal pain, and vomiting. I would have totally missed it had he not said at one point "pain between my shoulder blades". It was something said among 1000 other words over a span of 10 minutes I was in the room.
 
Speaking of weird cases, had a guy yesterday who had been fishing all day. Ate a salad and then had a "funny sensation in his throat" and "pounding sensation in his head" followed by numerous episodes of vomiting and diarrhea. Arrived in ED with BP in the 70's and HR of 40-50. EKG shows sinus brady. Labs all normal except for lactate of 2.5. Denies any chest pain, back pain, abdominal pain, dyspnea, or headache. EKG without ST-T changes, trop negative, CXR negative. Exam had no abdominal tenderness.

Thoracic Aortic Dissection... TTE upstairs showed a dilated root with regurgitation. STAT CTA then ordered. Went to the OR. Again, no chest, back, or abdominal pain. I didn't diagnose it. Curious how many would've ordered a CT on someone in their 70's with no abdominal tenderness/pain or chest pain.
That’s ****ed up. Clown shoes man, clown shoes.
 
Out of all the fuucked up electrolytes she has, the extremely low potassium is the single most deadly one. This has to be addressed first by the EP. You can get instant death from the resultant cardiac arrhythmia.

In fact I bet she had a cardiac arrhythmia that produced syncope which lead her to come to the hospital. I don’t think she had a seizure although its on the differential.

@dadaddadaBATMAN no criticism here for sending urine lytes and i would send other non-emergency stuff too. But can’t sit around and wait for them to return and skimming through UTD looking up the urine sodium values differentiating SIADH versus other stuff. It’s that K+ that has to be fixed!

The only other time i had a K+ of 1.8 the ICU doc wanted a central line and was nice enough to come down and place a subclavian one himself. These patients tend to have a massive whole body potassium deficit, more than one would expect by subtracting 4.0 - 1.8 = 2.2 mmEq down.

I don’t have a problem with the neuro workup first and i agree with the commentary that giving tPa with a clean angio with no focal neuro deficits is just Neuro covering their ass.

I would have called Nephro and ask their opinion on optimal resus in this case. They sometimes are good at identifying novel crystalloid replacement solutions with additives that we don’t think of.

I think she needs a line. Tube. Foley.
Good case. When I graduated from residency I was good at identifying this electrolyte imbalance shiit but working in a community hospital really sucks the intellectual curiosity out of you.

I agree with essentially everything here, but mostly I’m just really impressed you had the patience to type out that username. If it weren’t saved I would just quit this site I think
 
I agree with essentially everything here, but mostly I’m just really impressed you had the patience to type out that username. If it weren’t saved I would just quit this site I think

Ha! I have no patience! When you type the @ symbol and the first few letters “dada” the browser pops up account names and i pick one.
 
So what happened to the patient RF. She is basically comatose with normal vital signs and deranged electrolytes. Was she slipped GHB which would explain 2 of those 3 things?

Hypokalemic periodic paralysis? What’s that diagnosis called again?

Is she taking natural weight loss pills that are diuretics, which lowered her Na and K+?

Let’s wrap this up, get to the punch line.
 
Out of all the fuucked up electrolytes she has, the extremely low potassium is the single most deadly one. This has to be addressed first by the EP. You can get instant death from the resultant cardiac arrhythmia.

In fact I bet she had a cardiac arrhythmia that produced syncope which lead her to come to the hospital. I don’t think she had a seizure although its on the differential.

@dadaddadaBATMAN no criticism here for sending urine lytes and i would send other non-emergency stuff too. But can’t sit around and wait for them to return and skimming through UTD looking up the urine sodium values differentiating SIADH versus other stuff. It’s that K+ that has to be fixed!

The only other time i had a K+ of 1.8 the ICU doc wanted a central line and was nice enough to come down and place a subclavian one himself. These patients tend to have a massive whole body potassium deficit, more than one would expect by subtracting 4.0 - 1.8 = 2.2 mmEq down.

I don’t have a problem with the neuro workup first and i agree with the commentary that giving tPa with a clean angio with no focal neuro deficits is just Neuro covering their ass.

I would have called Nephro and ask their opinion on optimal resus in this case. They sometimes are good at identifying novel crystalloid replacement solutions with additives that we don’t think of.

I think she needs a line. Tube. Foley.
Good case. When I graduated from residency I was good at identifying this electrolyte imbalance shiit but working in a community hospital really sucks the intellectual curiosity out of you.

This is in line with my take. Needs a line for K replacement NOW, presumed arrhythmogenic syncope. This is getting out of EM and going to upstairs care, but her labs are very odd and hard to put together into a complete picture. Just to kind of work through them

PLT 753
Na 120
K 1.7
CO2 23
Ca 6.3
Alb 1.8
BUN 89
Cr 3.56
AG 20
ABG 7.37 / 37 / - 3.6

Na 120 with an SPG of 1.017, likely just points toward tubular dysfunction as opposed to primary polydipsia, esp given the renal function

ABG essentially normal with a gap of 20, corrected gap for albumin is actually higher. Significantly elevated delta ratio with normal pCO2 suggesting concurrent metabolic alkalosis. What's the source of the gap?

Calcium of 6.3 with alb of 1.8 corrects to 8.1ish. Normal calcium with normal bicarb makes me think of a more acute renal process

Alb of 1.8 - negative acute phase would make sense with the thrombocytosis of 753, in the setting of what appears to be acute renal dysfunction, and has WBC and WBC clumps, could think about nephrotic syndrome but doesn't have very impressive proteinuria on UA

So, youngish lady with probably? acute-ish process leading to acute renal failure with active sediment? Hypokalemia might be more tubular dysfunction and K wasting process. Urine /serum osm, urine lytes would be interesting. Would want nephro to come by
 
Hypokalemic periodic paralysis? What’s that diagnosis called again?

Thyrotoxic Periodic Paralysis. That's what initially came to my mind when I looked at this case, however that's not it here, as stated by OP. Usually male presentation, presents with LE paralysis. Had this case in residency. Young male came in saying he can't move or feel his legs. Attending takes an 18 gauge needle and pokes him in his thigh and feet, does nothing. During this time, he becomes unconscious and the monitor shows v-fib. 200 joules later, wakes up immediately. Potassium was 1.8. Very rare disease though.

For the med students/residents, here's a little more info:

Thyrotoxic Periodic Paralysis

I would at least have this in the differential in a severe symptomatic hypokalemia case.
 
Also, just remember med school biochem: the sodium/potassium pump is magnesium dependent. If there is a low K, and a low mag (of which you are not aware), you can lethally inject the pt with K, and it won't bump. I'm still hoping that someone measured it and it will get posted.
 
MAN, I slept like, ALL DAY. I had a dream where I invented an unbreakable baseball bat, and only ONE bat would be used per game.

Can baseball come back, pleeeze?

So, she's still in the ICU.

Her Mg was normal.

She had v-fib arrests x2 in the ER, both responded to defibrillation.

No joke: Never in 8 years (since residency) did I have so many difficulties giving potassium.

I entered the "ICU K+ replacement protocol" in the computer.

"That protocol isn't crossing over in CERNER, can you order something else?"

I entered "20 mEq K IV STAT".

"Dokterrrrr, that's not crossing over and we dont have it in the pyxis."

Eventually, I gave up and just said: "I don't effing care how we get this woman potassium; make it happen."

She got potassium, somehow; but nevermind that - I just checked a few minutes ago, and she's still clocking a K in the low 2 range.

She's off the vent and is talking.

She seriously, seriously, didn't "eat anything that wasn't blessed by mother earth" and basically starved herself into the ICU.
My point with the physical exam findings was : "Something doesn't add-up here; she's all mother-earth-granola-all-natural but has fake tiddies."
Her husband (No joke, saw him in the hospital cafeteria 2 days ago) is still more interested in his tractor and cigarettes.

That "rasta blowing a flute" toe ring is now seared into my brain, as is the phrase "the left and the right wings are part of the same bird".
 
The bird thing is a little ridiculous but the flute playing dude is actually a native american fertility God, not a rasta dude.


That "rasta blowing a flute" toe ring is now seared into my brain, as is the phrase "the left and the right wings are part of the same bird".

Had a similar although less healthy at baseline patient the other night.

Persistent K <2, bicarb undetectable, pH 6.88 and sodium of 120 (until the inpatient team slammed 200mEq of HCO3 in), Scr of 2.5.

Had displaced her feeding tube 6 days before and had zip for intake in that time period because "Nothing tastes good"
 
Speaking of weird cases, had a guy yesterday who had been fishing all day. Ate a salad and then had a "funny sensation in his throat" and "pounding sensation in his head" followed by numerous episodes of vomiting and diarrhea. Arrived in ED with BP in the 70's and HR of 40-50. EKG shows sinus brady. Labs all normal except for lactate of 2.5. Denies any chest pain, back pain, abdominal pain, dyspnea, or headache. EKG without ST-T changes, trop negative, CXR negative. Exam had no abdominal tenderness.

Thoracic Aortic Dissection... TTE upstairs showed a dilated root with regurgitation. STAT CTA then ordered. Went to the OR. Again, no chest, back, or abdominal pain. I didn't diagnose it. Curious how many would've ordered a CT on someone in their 70's with no abdominal tenderness/pain or chest pain.


this was chronic / incidental.
 
this was chronic / incidental.

I think this is the case in a lot of "crazy" aortic dissection cases. Believe, me I hunt for dissections like crazy (even the radiologists tell me I order too many CTAs). However, I think sometimes we attribute symptoms to the dissection that are simply not the case. Not that I have any absolute gold standard for this, but a lot of type B dissections can occur and be present for weeks, months, years. The patients don't all rupture and die immediately. I believe in some cases the dissection is/has been present for a long time and then when the patient comes to the ER with their sore throat, finger tingling, nasal congestion, whatever bs symptom today and by some convoluted workup eventually leads to the diagnosis of the incidental dissection we then work backwards and assume "nasal congestion can be a symptom of a dissection!"
 
Just curious, did she ever have a CK drawn? Renal failure with large blood on the dip but not many RBCs with red urine has me thinking myoglobin.

She did; but it was normal.
One of the points I was trying to make with my physical exam description was the hypocrisy of "I only eat all natural, blessed-things, because my body is a temple. But Fake Tiddies are cool because Fake Tiddies."

This is a microcosm of a lot of the *******ery that I run into every shift.
 
My turn. Had this last night

"Attendings; let the students/terns have first crack at questions/details/advancing the case.
Snarky-ass comments welcome." - still applies!

26 yo woman p/w dizziness, vomiting, and not feeling well. Onset maybe 1 hour ago. Just had NSVD 7 days ago at OSH, treated for peripartum pre-eclampsia. She is otherwise healthy.

HR 125. BP 150/130. RR low 20s. SpO2 98% RA. Temp normal

She looks pale. A little sleepy. She looks kind of ill
She is speaking as if she has a bag of marbles in her mouth. I looked in her mouth and there aren't any.
I keep on having to yell her name, and her eyes will open and answer my questions.

Me: me yelling..."How do you feel?"
Her: She opens her eyes. "Yea I'm feeling OK. I'm nauseus." Then closes her eyes
Me: me yelling..."Do you have any pain?"
Her: she opens her eyes. "No not right now. maybe earlier had a headache. But I'm OK now." then closes her eyes
Me: me yelling..."do you have any chest pain, problems breathing, nausea, vomiting, diarrhea, any other pain anywhere?"
Her: she opens her eyes. "Umm....no." then closes her eyes.

Me: me yelling..."How did your delivery go? Any problems?"
Her: she opens her eyes. "yea it was fine...they said I had pre-mpns.dips.disbabdbaba. they gave me to much...umm..megnesssnimum" then closes her eyes.
Me: me yelling..."do you have any vaginal bleeding?"
Her: she opens her eyes. "yea some" then closes her eyes

Family isn't around. EMS said basically she was dizzy and started vomiting. That's about it.

I just decided to examine her because it was painful getting answers. I could only understand about 3/4 of what she said. It was dysarthria not dysphasia.
Ocular movements are not normal. She gazes normally to the left. Hard time gazing to the right. There was right horizontal nystagmus. I thought this was cool. There was a hot tech in the room and I said "psst! check this out!" I had the patient do it again and now she wasn't doing that nystagmus. (Internally I said dammit!!!!!")
Extremely easily moves all extremities like 6/5. Even kept pointed toes. She put her legs straight in the air. One of the nurses said "are you a dancer?" She opened her eyes, smiled, and said "yes I am" then closed her eyes.
Abd is very soft, no tenderness
No CVAT
Lungs clear
has 1-2+ pitting edema in legs
2+ patella reflexes b/l

giphy.gif


Before you even ask.
FSG normal
Yes I get a stat Head CT and it's normal
 
My turn. Had this last night

"Attendings; let the students/terns have first crack at questions/details/advancing the case.
Snarky-ass comments welcome." - still applies!

26 yo woman p/w dizziness, vomiting, and not feeling well. Onset maybe 1 hour ago. Just had NSVD 7 days ago at OSH, treated for peripartum pre-eclampsia. She is otherwise healthy.

HR 125. BP 150/130. RR low 20s. SpO2 98% RA. Temp normal

She looks pale. A little sleepy. She looks kind of ill
She is speaking as if she has a bag of marbles in her mouth. I looked in her mouth and there aren't any.
I keep on having to yell her name, and her eyes will open and answer my questions.

Me: me yelling..."How do you feel?"
Her: She opens her eyes. "Yea I'm feeling OK. I'm nauseus." Then closes her eyes
Me: me yelling..."Do you have any pain?"
Her: she opens her eyes. "No not right now. maybe earlier had a headache. But I'm OK now." then closes her eyes
Me: me yelling..."do you have any chest pain, problems breathing, nausea, vomiting, diarrhea, any other pain anywhere?"
Her: she opens her eyes. "Umm....no." then closes her eyes.

Me: me yelling..."How did your delivery go? Any problems?"
Her: she opens her eyes. "yea it was fine...they said I had pre-mpns.dips.disbabdbaba. they gave me to much...umm..megnesssnimum" then closes her eyes.
Me: me yelling..."do you have any vaginal bleeding?"
Her: she opens her eyes. "yea some" then closes her eyes

Family isn't around. EMS said basically she was dizzy and started vomiting. That's about it.

I just decided to examine her because it was painful getting answers. I could only understand about 3/4 of what she said. It was dysarthria not dysphasia.
Ocular movements are not normal. She gazes normally to the left. Hard time gazing to the right. There was right horizontal nystagmus. I thought this was cool. There was a hot tech in the room and I said "psst! check this out!" I had the patient do it again and now she wasn't doing that nystagmus. (Internally I said dammit!!!!!")
Extremely easily moves all extremities like 6/5. Even kept pointed toes. She put her legs straight in the air. One of the nurses said "are you a dancer?" She opened her eyes, smiled, and said "yes I am" then closed her eyes.
Abd is very soft, no tenderness
No CVAT
Lungs clear
has 1-2+ pitting edema in legs
2+ patella reflexes b/l

giphy.gif


Before you even ask.
FSG normal
Yes I get a stat Head CT and it's normal

I rarely had contact with the preggers except the rare occasion in the ICU as a resident. Pre-E with PRES? Pound the mag and labetalol while getting cardene
 
C’mon son, you gotta give us a real BP. Nobody is getting a 150/130 BP and saying “okay, that sounds legit. No need to repeat.”
 
I would not make emergency management decisions pending the result of a TSH. Most places it doesn't even come back quickly. Takes a day.

It's fine to send that off for the inpatient team, and in fact I would send off several other labs too that come back later.

But this patient is critically ill and you don't order MRI's and TSH's trying to find a diagnosis in the ED. You do a good history, physical exam, pattern recognition, and come up with a list of the top killers (and especially those you can fix) that she could have and address them immediately. What's potentially interesting about this case is she has normalish vital signs yet is markedly obtunded.

I’d agree on the MRI, but particularly on an obtunded patient draw the rainbow and fire all your lab work bullets up front. History is going to be a game of telephone, and questionable at best in a case like this. I’ve never worked in a department where TSH didn’t result with roughly the same speed as other more common EM labs.

Outside of concerns for myxedema coma in this case, any ED patient that I am treating for CHF who also happens to be on synthroid who doesn’t have a recent TSH in the medical record gets one as hypothyroidism is associated with higher right atrial pressures, lower ejection fractions, a higher risk of CHF exacerbations (which translates into more unpaid bouncebacks If you discharge someone), and mortality.
 
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PRES vs CVT vs CVA vs TTP vs endometritis
Eventually needs MRI/MRV (in ED or upstairs)
Consider CTV in the meantime, maybe CTA r/o basilar thrombus given nystagmus
Control BP, consider empiric AC for CVT after negative HCT (make sure not hemolysing given paleness and tachycardia)
Empiric abx
Admit ICU
 
PRES vs CVT vs CVA vs TTP vs endometritis
Eventually needs MRI/MRV (in ED or upstairs)
Consider CTV in the meantime, maybe CTA r/o basilar thrombus given nystagmus
Control BP, consider empiric AC for CVT after negative HCT (make sure not hemolysing given paleness and tachycardia)
Empiric abx
Admit ICU

Would favor this, and it’s basically my ddx. Only thing I’d add that probably isn’t relevant is that eclampsia is also a post partum Dx (up to 6-12weeks depending on source) should be considered with end organ damage and that bp. Still needs labs and Icu, call to her ob, abx, would probably get cta ctv and discuss with neuro if time course and hard findings were convincing.
 
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